Family Game Show-style Didactic for Teaching Nervous System Disorders during Emergency Medicine Training

Audience Emergency medicine residents and medical students Introduction The field of emergency medicine requires learners to build a vast library of illness scripts to be accessible in a rapid manner. Illness scripts are refined and reinforced as senior physicians teach learners common associations between diagnoses, presentation, workup findings, and treatment modalities.1 In order to examine these associations, we developed a didactic session based on the popular television game show “Family Feud” to teach important neurologic conditions related to emergency medicine. This lecture was designed to be an interactive competition, leveraging group participation, competition, and expert opinion. Neurologic emergencies are very common, affecting millions of Americans yearly. It is important for emergency medicine physicians to quickly recognize these conditions and initiate treatment because delay can lead to devastating outcomes.2 The neurologic conditions covered in the lecture were chosen based on the 2016 EM model of clinical practice, sections 7.0: Head, ear, eye, nose, throat disorders, 10.0: Systemic infectious disorders, 12.0: Nervous system disorders, and 19.0: Procedures and skills integral to the practice of emergency medicine, as well as author experience. Educational Objectives By the end of this didactic exercise the learner will: 1) name 13 important neurologic conditions related to emergency medicine: TPA (tissue plasminogen activator) contraindications/TPA eligibility, optic neuritis, botulism, giant cell (temporal) arteritis, viral encephalitis, neurocysticercosis, rabies, myasthenia gravis, neurosyphilis, status epilepticus, Bell’s palsy, dementia vs. delirium, acute inflammatory demyelinating polyneuropathy (Guillain-Barré); 2) recognize five pattern words associated with each neurologic condition; 3) understand exam findings, diagnostic tests, and/or treatments for 13 important neurologic conditions. Educational Methods A survey was sent through a national emergency medicine education listserv (Council of Residency Directors in Emergency Medicine [CORD-EM]) asking educators to list common word or phrase associations that come to mind with a list of neurological diagnoses. A PowerPoint lecture was created in the form of the game, Family Feud, using the data from this national survey. The game Family Feud requires participant teams to guess answers to certain questions by attempting to guess the most popular answers of survey respondents. At our weekly residency conference, residents were divided into teams and offered the opportunity to compete in a game testing knowledge of nervous system disorders. Each neurology topic was then addressed by a mini-lecture to review pertinent concepts in the disease process. There was no formal assessment at the end of this lecture; however, learners actively participated throughout the lecture. Questions were discussed at the end of each round giving learners the opportunity to fully understand topics. Research Methods Efficacy of the educational content was assessed based on learner feedback as well as observation of the learners during the exercise. Results Learners were engaged with the exercise and verbal feedback was uniformly positive. Learners were enthusiastic about the format and requested more sessions created in a similar game. Discussion Based on feedback as well as observation of the learners, the lecture was both an effective highyield neurology refresher and team-building exercise. Learners enjoyed the opportunity to compete as a team. Gamification seemed to improve student enjoyment, engagement, and attention, which has also been shown in the literature.3 Our residency program intends to implement similar lectures in the future. Topics Neurology, TPA contraindications, TPA eligibility, upper motor neuron lesion, lower motor neuron lesion, optic neuritis, aphasia, botulism, ACA (anterior cerebral artery) stroke, giant cell (temporal) arteritis, Bell’s palsy, viral encephalitis, Todd’s paralysis, neurocysticercosis, tonic-clonic seizure, rabies, epidural hematoma, myasthenia gravis, spinal cord injury, neurosyphilis, Glasgow Coma Score (GCS), status epilepticus, Horner’s syndrome, subarachnoid hemorrhage, dementia, delirium, Parkinson’s disease, acute inflammatory demyelinating polyneuropathy (Guillain-Barré).


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We included the following conditions in the survey on the CORD listserv: Optic Neuritis, Guillain Barré, NIH Stroke Scale, TPA Contraindications, Botulism, Tick Paralysis, Neurosyphilis, Status Epilepticus, Delirium, Lumbar Puncture, Myasthenia Gravis, Bell's Palsy, Rabies, Neurocysticercosis, Temporal Arteritis, and Viral Encephalitis. We coded responses "keywords" to each question and grouped common themes together. Of the departmental faculty and fellows surveyed, we received 18 responses (response rate: 67%). We received 77 responses from our query on the CORD-EM listserv. These responses were collected in August 2018. We included survey results from faculty and CORD-EM faculty in our final results (Table I). Based on which conditions had the most straightforward survey responses, the senior author selected the following conditions for inclusion in the game: TPA contraindications, Botulism, Idiopathic facial nerve palsy (Bell's palsy), Giant-cell arteritis (Temporal arteritis), Viral encephalitis, Neurocysticercosis, Status epilepticus, Rabies, Myasthenia gravis, Neurosyphilis, Delirium, and Acute inflammatory demyelinating polyneuropathy (AIDP/Guillain-Barré Syndrome, and Optic neuritis.

Slide preparation:
The host prepares the PowerPoint by preparing slides for the a) pre-round question (insert a PowerPoint slide with the preround question into the deck) b) the survey responses c) summary slides. Each round will consist of a pre-round question, an animated survey slide, and a summary slide. We imported survey results, which are included in Table 1, into a game style PowerPoint, which can be found at: http://www.youthdownloads.com/games/family-fuedpowerpoint. 5 The following YouTube (https://www.youtube.com/watch?v=Lo4VkGHzt3k) video provides an overview on how to import answers into slides. 6 Exemplar slides are available in the supplemental files of this publication.

Game play:
It is recommended that the pre-round question be used to determine which team will play the round (see Appendix 1). The educational host reads the pre-round question. Teams can buzz in to try to answer the pre-round question; teams are disqualified from the pre-round question if they buzz in before the entire question is read. The winner of the pre-round question becomes the team that will have the first opportunity to guess the keywords for that round. The host reads the survey question as: "What comes to mind when you think of [condition]." Teams earn points for every keyword answered correctly. For example, if a team guesses "honey" for the botulism question, they would earn 38 points, corresponding to how many survey respondents gave that answer. Teams can either discuss answers as a group or answer one at a time, depending on the learner comfort and level. If the team was not able to guess all keywords prior to having three incorrect answers ("strikes"), the remaining teams will have the opportunity to buzz in to guess any remaining keywords. The first team to buzz in with a correct keyword earns the points from that keyword and the opportunity to guess any remaining keywords. Play is continued in this fashion until all keywords have been guessed, allowing each team up to three strikes per round until all keywords have been guessed. In our experience, no more than two teams usually participate in each round. After all keywords are guessed, the host provides teaching pearls about the condition. Teaching pearls for each condition are included in Appendix 2.

Results and tips for successful implementation:
This exercise was presented during residency conference for a group of approximately 24 emergency medicine residents and medical students. We did not obtain a direct assessment of learner acquisition of knowledge. Efficacy of the educational content was assessed based on learner feedback as well as observation of the learners during the exercise. We observed high learner engagement and enjoyment. No modifications were needed after initial implementation, although we found it is best implemented in a group setting with between one and six learners per group and two to six groups.

Associated content (optional):
Please find the attached Appendices 1 and 2 for pre-round questions and teaching pearls from each round.

Technology necessary:
A computer and projector are required to present the questions in PowerPoint format. Audience response buzzers are required to determine which team will play for points during the next round. There are a multitude of audience response systems available. We used "Eggspert" buzzers; however, one could use any audience response system that can allow a team to buzz in first. 7 We used a premade family trivia-style PowerPoint, which can be found at http://www.youthdownloads.com/games/family-fuedpowerpoint. 5 If using the PowerPoint templates and/or buzzers is too resource intensive, one could easily play the game using a dry erase board to record answers and points and asking questions verbally. One could also have students raise their hands instead of using an audience response system. The PowerPoint is advantageous because summary slides can also be added; however, these summaries could also be discussed verbally without PowerPoint. Similarly, the pre-round questions could also be read aloud instead of shown on slides.

Assessment (optional):
We did not formally evaluate learners after this intervention. However, learner understanding was assessed by the interactive nature of the game throughout play. Learners were engaged throughout the entirety of the implementation. After completing the exercise, learners expressed that they found the exercise entertaining as well as valuable for refreshing neurology knowledge. Ascending weakness (56) Areflexia (6) Vaccines (5) Campylobacter/diarrhea (5) NIF (2) Botulism Honey (38) Floppy baby (14) Canned food (10) Cranial nerve palsy (8) IV drugs (6) Delirium Withdrawal/ Alcohol (19) Urinary tract infection (16) Waxing/waning (9) Confusion (5) Elderly (5) Giant-cell arteritis (Temporal arteritis) ESR (33) Elderly (14) Jaw claudication (7) Headache (7) Biopsy (5) Steroids (5) Temporal tenderness (3) Bell's Palsy Forehead involvement (24) Facial nerve (19) Lyme disease/tick (11) Steroids (5) Eye drops (2) Myasthenia gravis Ptosis/diplopia (27) Edrophonium/ tensilon test (15) NIF/VC/FVC (15) Ice pack test (7) Fatigue/tired/ gets worse (4) Neurocysticercosi s Pork (39) Latin American (14) Seizures (10) CT hyperdensities/calcifications (7) HIV/Immunodeficienc y (4) Tapeworm (3) Neurosyphilis Penicillin (15) Dementia/crazy (10) Tabes dorsalis/posterior column (8) Tuskegee (6) Elderly (3) Missed (3) Lumbar puncture (3) Argyll-Robinson pupil Optic neuritis Multiple sclerosis (59) Red color desaturation (9) Vision loss (9) Painful (5)  Appendix A: Pre-round Questions The following questions were used to determine which team would play for the next round. For example, the pre-round question for round one was asked at the beginning of round one. The teams used an audience response system to buzz in sequentially after the question was read by the host. The team who activated their audience response buzzer first would be able to answer the pre-round question first. If the pre-round question was answered correctly, that team would have the opportunity to guess the round. If the team answered incorrectly, the remaining teams were given the opportunity to buzz in to answer the question. If the second team answered correctly, they would then get to guess the round. If they were incorrect, the remaining teams would then have the opportunity to buzz in until the question was answered correctly and the team who would guess the round was determined.

Pre-round question 1:
Question: A patient comes in with right sided hemiparesis. What is the ONE lab you need to check first? Answer: Glucose Explanation: Hypoglycemia is known to cause stroke-like symptoms. It is even possible to see abnormal findings in imaging studies in the setting of hypoglycemia. Hypoglycemia is usually an easily correctable condition. Once glucose is corrected, the hemiparesis often resolves. Therefore, it is critical for learners to recognize that evaluating blood glucose levels, particularly before giving therapeutic agents such as tissue plasminogen activator (TPA), is a critical action in patients presenting with neurologic deficits. 8 -Poor repetition and naming -Good auditory comprehension Answer: Broca's (expressive) aphasia Explanation: Broca's aphasia is an expressive aphasia meaning the patient has good comprehension but is unable to express his responses verbally or in written form. Patients may experience difficulty with word finding, hesitancy, non-fluency, repetition, or appear confused with relatively spared auditory comprehension. These symptoms are usually associated with infarction (middle cerebral artery), infection, inflammation, or other damage to Broca's area of the brain (motor center in the left posterior inferior frontal cortex and insula). 12,13 Pre-round question 4: Question: Where is the stroke? -The patient has isolated leg paresis Answer: Anterior cerebral artery (ACA) Explanation: The homunculus describes anatomical connectivity between limb and brain. It was developed in 1937 and since has undergone some revision. It still roughly correlates brain lesions to anatomic structures. The ACA is associated with lesions such as lower and upper extremity weakness, apraxia, aphasia, and language dysfunction. Lower extremity weakness is usually worse than upper extremity weakness. [14][15][16] Pre-round question 5: Question: A 32-year-old female in 3rd trimester of pregnancy presents with sudden onset hemifacial weakness, diminished taste, hyperacusis, and difficulty closing one eye. Diagnosis? Answer: Idiopathic facial nerve palsy (Bell's palsy). Explanation: Pregnancy is a hypercoagulable state, and thus pregnant patients are at increased risk for stroke. It is important to be able to distinguish the features of stroke with more benign conditions such as idiopathic facial nerve palsy. Idiopathic facial nerve palsy has an incidence of 24-40 per 100,000 people, is more common in women than men, and may be approximately 6-fold higher in pregnant women than nonpregnant women, though this is controversial. It occurs most commonly in the 3rd trimester or peripartum period. Steroids should be avoided in the first trimester; however, acyclovir is pregnancy category B and can be started within three days of onset. 17 Pre-round question 6: Question: The patient has a focal nerve deficit after a seizure. What is the common name for this? Answer: Todd's paralysis. Explanation: Ictal paresis and postictal paresis (Todd's paralysis) are rare seizure manifestations. Patients present with transient motor deficits during or after a seizure. Symptoms can occur in patients presenting with first time seizure as well as recurrent epilepsy. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) findings will be suggestive of seizure activity without evidence of ischemia. The deficits may last for one week after seizure, though most often duration is minutes to hours. It may be related to seizure activation or inhibition of a sensorimotor region of the brain. [18][19][20] Pre-round question 7: Question: What type of seizure is this? -Stiffening of the body followed by jerking of the body -Loss of consciousness -Post-ictal period -Incontinence Answer: Tonic-clonic (grand mal) Explanation: Tonic-clonic or grand mal seizures, also characterized as general seizures, are full-body, nonfocal seizures with loss of consciousness. Seizures lasting longer than five minutes require treatment with benzodiazepines or anticonvulsants. Most (60%-70%) patients with recurrent seizures gain symptom control with anti-epileptic medications. 21,22 Pre-round question 8: Question: A football player is knocked unconscious after he is tackled without his helmet on. He then wakes up and feels fine. He is sitting on the bench...then he becomes lethargic. What is the injury? Answer: Epidural hematoma Explanation: Epidural hematoma can occur from trauma of various types and is defined as a collection of blood between the dura and the skull. It appears as a lenticular shaped hematoma on imaging, usually due to injury of the middle meningeal artery or vein. Patients sustain the injury, then usually have loss of consciousness followed by a period of alertness (but often appear confused). This alert period is characterized as the lucid period. The patient may then become progressively confused and lethargic. Epidural hematomas can develop quickly leading to rapid decline in mental status. Patients with these injuries require immediate neurosurgical intervention. 23,24 Pre-round question 9: Question: A trauma patient does not have triceps function. Where is the spinal cord lesion? Answer: C6/C7. Explanation: Spinal cord lesions are associated with specific motor deficits. The cervical spine accounts for over 50% of spinal cord injuries. The triceps, wrists, fingers, torso, and lower limbs all have some function from the C5-C7 level. An injury at this level is expected to cause deficits in the above anatomic areas. Primary injury is caused by shearing/compression forces, associated vascular disruption, and cell death. Secondary injury is caused by ischemia, inflammation, and excitotoxicity. 25 Pre-round question 10: Question: What is the Glasgow Coma Scale (GCS) of the patient below? A 23-year-old male presents after a motor vehicle accident. He opens his eyes when asked, is disoriented and confused, and is able to pinpoint the location of his pain. Answer: GCS 12 (eyes=3, verbal=4, motor=5). Explanation: The GCS is a widely used scoring system to assess a patient's level of neurologic function. The GCS was initially designed for patients with head trauma but is also used to assess level of consciousness in Pre-round question 12:

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Question: Patient has a sudden, severe, thunderclap headache. Computed tomography (CT) is negative. What is the next test? Answer: Lumbar puncture Explanation: Severe, sudden onset headache is also known as a thunderclap headache. It can occur due to many causes; however, the most concerning of these causes is a subarachnoid hemorrhage (SAH) due to aneurysm rupture. A broad differential should be assumed; however, sudden, non-traumatic headache onset in patients with risk factors should be evaluated for SAH. SAH is defined as bleeding into the subarachnoid space between the arachnoid membrane and pia mater. Treatment is by surgical clipping or endovascular repair. Diagnoses can be by computed tomography (CT) and/or lumbar puncture if CT is negative. 29,30 Pre-round question 13: Question: A patient exhibits the following symptoms. What is the diagnosis? -Pill rolling tremor -Akinesia/bradykinesia -Rigidity -Kyphosis -Shuffling gait Answer: Parkinson's disease Explanation: Parkinson's disease is a progressive disease encompassing movement as well as cognitive dysfunction. The symptoms above are characteristic of some of the gait and tremor abnormalities associated with the disease. Other nonmotor symptoms include sleep disorders, constipation, and hyposmia, as well as cognitive decline and psychiatric manifestations. The progressive nature is usually slow and on the order of years to decades. Levodopa therapy remains commonplace in Parkinson's treatment; however, is not without complications. Surgical treatments are also available and are at various stages of development. 31